Event Notification Report for November 26, 2020

AGREEMENT STATE REPORT - MEDICAL REPORT - UNDERDOSE

The following was received from the State of Kentucky via email:

"The Kentucky Radiation Health Branch was notified by the Radiation Safety Officer of a medical event at Norton Hospital Interventional Radiology Downtown Campus, Louisville KY (RML No. 202-031-26). Deviation from Y-90 Therasphere treatment dose to a patient was immediately identified due to a leak between the administration kit and the microcatheter used in administration of the dose. The situation was remedied by tightening the connection at the junction, and no further loss of material was observed. Spillage was confined to patient drape and follow-up surveys for external contamination on the patient and staff present were conducted. The room and staff were subsequently cleared of any radioactive contamination. The patient dose assessment was estimated using the patient waste and the spill waste and it was determined that the delivered dose was 93 Gy which was 68 percent of the prescribed dose of 135 Gy. Initial root cause analysis indicated that the administration set received from the manufacturer was a different kit from the previous set, and a mismatch resulted in a leaky junction. The licensee has contacted the manufacturer (Boston Scientific BTG) to resolve this situation."

Kentucky Event Report ID No.: KY200006

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.